Efficacy of Cognitive Behavioral Therapy With and Without Medication for Adults With ADHD

ADHD in adulthood goes hand in hand with problems in key areas daily living, such as work, family life, and social / interpersonal functioning. These are often accompanied by emotional problems, such as depression, anxiety, anger and low self-esteem. Such difficulties may stem from poor skills in organization, time management, planning, and emotion regulation. Cognitive behavioural therapy (CBT) – an established treatment for many psychological problems – has more recently emerged as a promising treatment for adults with ADHD. Cognitive behavioural treatments for adults with ADHD are specifically tailored to addressing their key problem areas and developing skills and compensatory strategies to foster needed improvements. Randomized clinical trials have found such treatments to be efficacious [1, 2], however they have mostly been carried out in groups of medicated patients or in mixed groups of medicated and unmedicated patients. Hence, it has remained unclear whether CBT should be used in combination with medication or whether it can also be an effective standalone treatment for those adults who cannot or do not wish to be medicated.

In our randomized trial, we had therefore set out to compare the effects of a group CBT treatment for adults with ADHD administered alone versus in combination with stimulant medication. The CBT focused on key problem areas for adults with ADHD, such as goal attainment, executive functioning (organization, time management, planning), self-esteem, emotion regulation, impulse control, and relationships. Skills and strategies were covered in session and implemented and practiced as “homework”. To aid with skill practice and implementation, each patient was assigned a coach (mostly junior staff, such as research assistants). The coaches phoned the patients twice a week for 10-15 minutes to help them stay on track with their “homework”. This was a unique feature of our protocol.

At the end of the 12-week treatment, we found that the combined treatment outperformed CBT alone in terms of improvement in ADHD symptoms, organizational skills and self-esteem. However, differences in outcomes between the treatments diminished in these areas over the 6-month following CBT: those who had received CBT alone continued improving over the follow-up, while those who had received the combined treatment maintained their gains. The continued improvement in the CBT alone group was reminiscent of a sleeper effect sometimes seen in psychotherapy studies [3]. We suspect that it may have been fostered by the coaching that continued over the follow-up phase. Coaching was rated as a highly helpful component of the program in feedback evaluations, and we believe that it warrants further study as a component of CBT for ADHD. It is not clear why the patients who underwent the combined treatment did not experience the same continued improvement. As one possibility, they may have reached their full improvement potential by the end of the 12-week treatment, as the combined treatment produced more rapid gains. We conclude that, while the combined treatment produces greater, more immediate benefits, similar levels of improvement may be reached more gradually with CBT alone – at least in the presence of continued coaching support [4].